Advantage Plus Enrollment Form

Advantage Plus Enrollment Form
PLEASE PRINT USING BLACK OR BLUE INK.
Last name
First name
Date of birth (mm/dd/yyyy)
Gender
Male
Female
Permanent residence (do not use P.O. Box)
Street address
Middle initial
Home phone (include area code)
(
)
City
State ZIP
Mailing address if different from permanent residence (P.O. Box acceptable)
Address
City
State ZIP
Are you currently a Kaiser Permanente member?
Yes
No
If yes, please provide your Kaiser Permanente Medical Record Number (MRN)
I understand that my signature (or the signature of the person authorized to act on my behalf under the
laws of the State where I live) on this application means that I have read and understand the contents
of this application (including the “Conditions of enrollment” section on the back of this form). If signed
by an authorized individual (as described above), this signature certifies that: 1) this person is authorized
under State law to complete this enrollment; and 2) documentation of this authority is available upon
request by Kaiser Permanente Senior Advantage (HMO) or by Medicare.
Date signed
Applicant signature
Authorized representative must provide the following information
Name
Relationship to enrollee
Address
Phone (include area code)
(
)
PLEASE DO NOT SEND CASH OR CHECK. YOU WILL BE BILLED.
Return the signed form to: Kaiser Permanente
Medicare Department
P.O. Box 232407
San Diego, CA 92193–9914
WHITE • Return to Kaiser Permanente
YELLOW • Member’s copy/Retain for your records
Y0043_N003280_FinalNW03 CMS Approved (08/23/2010)
SKU 60258913 NW
Conditions of enrollment
The Advantage Plus optional supplemental benefits package is only available to members enrolled in
or applying for coverage in a Kaiser Permanente Senior Advantage Basic or Senior Advantage plan.
By completing this application form:
I agree to adding the Advantage Plus optional supplemental benefits package that gives me dental
coverage, hearing aids, and additional vision coverage for $41 per month, which is in addition to my
Medicare and Kaiser Permanente Senior Advantage premiums. I understand that the dental, hearing
aid, and vision coverage supplements my Senior Advantage coverage and is subject to the terms
and conditions stated in the Kaiser Permanente Senior Advantage Evidence of Coverage.
Kaiser Permanente is an HMO plan with a Medicare contract. Enrollment in Kaiser Permanente depends on
contract renewal. You must continue to pay your Medicare Part B premium. This information is available in a
different format by calling our Membership Services department at 1-877-221-8221 (TTY 1-800-735-2900
for the hearing/speech impaired), seven days a week, 8 a.m. to 8 p.m.
Please read carefully before you sign this form.